A nurse is admitting a client who is at 37 weeks of gestation and diagnosed with severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)
Evaluate neurologic status every 8 hr.
Provide a dark, quiet environment.
Administer magnesium sulfate IV.
Ensure that calcium gluconate is readily available.
Assess respiratory status every 4 hr.
Correct Answer : B,C,D
Explanation:
A. Evaluate neurologic status every 8 hr.
While monitoring neurologic status is important in clients with severe gestational hypertension to assess for signs of impending eclampsia (seizures), more frequent monitoring is typically required, such as every 4 hours or even more frequently depending on the severity of the condition. Therefore, evaluating neurologic status every 8 hours is not sufficient for this client.
B. Provide a dark, quiet environment.
Creating a calm and low-stimulation environment helps to reduce the risk of seizures, which can be triggered by bright lights and loud noises in clients with severe gestational hypertension.
C. Administer magnesium sulfate IV.
Magnesium sulfate is commonly used to prevent seizures in clients with severe gestational hypertension (preeclampsia). It is a standard treatment to prevent eclampsia, a serious complication of preeclampsia characterized by seizures. Therefore, the nurse should expect to administer magnesium sulfate IV as part of the management plan for severe gestational hypertension.
D. Ensure that calcium gluconate is readily available.
Magnesium sulfate, while effective in preventing seizures, can lead to magnesium toxicity if levels become too high. Calcium gluconate is the antidote for magnesium sulfate toxicity. Therefore, the nurse should ensure that calcium gluconate is readily available to counteract any potential magnesium toxicity that may occur during magnesium sulfate administration.
E. Assess respiratory status every 4 hr.
Monitor and record vital signs (blood pressure, pulse, respirations, O2 saturation) every 1 hour x’s 8 hours after maintenance infusion is started and vital signs for bolus infusion are complete. If respiratory rate < 12 breaths/min, draw magnesium level, notify HCP, and observe closely.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Explanation:
A. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors:
Fine tremors are a known side effect of terbutaline, which is often used to delay preterm labor by relaxing the uterus. While tremors are a common and expected side effect of terbutaline, they are not typically considered an urgent concern unless they are severe or accompanied by other concerning symptoms.
B. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes:
Proteinuria (2+) and increased deep tendon reflexes (2+) are significant findings in a client with preeclampsia, indicating worsening of the condition and potential organ involvement. However, they may not require immediate reporting unless accompanied by other severe symptoms such as severe hypertension, severe headache, visual disturbances, or epigastric pain.
C. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache:
This is the correct answer. Epigastric pain and unresolved headache are concerning symptoms in a client with preeclampsia and can indicate worsening of the condition or complications such as HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count). These symptoms may suggest liver involvement, which is a serious complication of preeclampsia and requires immediate evaluation and management by the provider.
D. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions:
While tearfulness and irregular, frequent contractions may indicate emotional distress or early labor, they are not typically considered urgent findings unless accompanied by other signs of impending preterm labor such as cervical changes or regular, painful contractions. Immediate reporting is important if there are signs of active labor or cervical changes, but based on the information provided, this finding is not as urgent as the epigastric pain and unresolved headache in a client with preeclampsia.
Correct Answer is C
Explanation
Explanation:
A. Pattern of contractions: While the pattern of contractions is important in assessing labor progress, it alone may not differentiate between true labor and false labor (also known as Braxton Hicks contractions). True labor contractions typically become longer, stronger, and more frequent over time, but other factors must also be considered to confirm true labor.
B. Rupture of the membranes: Rupture of the membranes (water breaking) can occur during both true labor and false labor. However, it is not a definitive sign of true labor on its own, as it can also happen spontaneously or due to other reasons.
C. Changes in the cervix: This is the correct answer. True labor is characterized by progressive changes in the cervix, including effacement (thinning) and dilation (opening). These changes can be confirmed through a cervical examination performed by a healthcare provider.
D. Station of the presenting part: The station of the presenting part refers to the position of the baby's head in relation to the mother's pelvis. While the station can provide information about the progress of labor, it is not a specific sign of true labor by itself.
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